Close Close

Life Health > Health Insurance

Scary benefits stories

Your article was successfully shared with the contacts you provided.

Consumer advocates would like to see health insurers do more to show consumers how insurance protects patients against health care catastrophes.

The advocates, who are known as consumer representatives, and have an official role in speaking for consumers in National Association of Insurance Commissioners (NAIC) proceedings, make that point in comments on federal efforts to update the official U.S. “health plan nutrition label.”

Drafters of the Patient Protection and Affordable Care Act of 2010 (PPACA) included the Summary of Benefits and Coverage (SBC) to give consumers a tool for comparing health plans on an apples-to-apples basis. An SBC, which is supposed to come with a standardized health insurance glossary, gives readers a brief description of what a plan does and does not cover.

The current version of the SBC includes two “coverage scenarios,” or examples of how a plan might cover a typical pregnancy and a typical case of type 2 diabetes. 

Federal regulators have proposed requiring SBC issuers to add a third scenario, for a simple fracture with an emergency room visit. Officials have suggested that the broken-bone scenario could appeal to young, healthy consumers who normally might see no reason to pay for health coverage.

Regulators want an SBC update to be ready for the 2016 open enrollment period, which is set to run from Nov. 1, 2015, through Jan. 31, 2016.

The NAIC has sent federal regulators a comment letter asking them to push implementation of the SBC update back until the 2017 open enrollment period. “Seemingly modest revisions require systemic changes to input the data into a new format, and time needs to be allowed for review by state insurance departments,” officials say in the letter.

If regulators require use of a half-baked temporary SBC format in 2016, they could make the SBC harder for consumers to understand, regulators say.

The consumer reps, meanwhile, have ideas about how to improve the SBCs.

Right now, for example, the rules don’t require a coverage issuer to provide an SBC for a consumer who signs up for special enrollment period (SEP) coverage until 90 days after the consumer has enrolled in the plan, the reps say. The reps say someone should fix that problem. 

The reps also want regulators to require SBC makers to put plan premium information on the first page of the SBC, and they have thoughts about expanding the SBC coverage scenario section.  

For a look at what the reps are saying about the coverage scenarios section of the SBC, read on.

Skeptical consumer

1. The reps think the scenario section of the SBC is easier for typical consumers to understand than other parts are.

The reps note that two studies revealed that consumers found the scenarios to be one of the most helpful SBC elements. The scenarios illustrate how cost-sharing works in a way that’s easy for consumers to understand, the reps say.

See also: Lynn Quincy: How you explain PPACA matters

A serious couple looking at a computer

2. The reps see the scenario section as the only tool consumers can easily use to rank plan choices based on a cost-sharing estimate.

Consumers can use the “Patient pays” total to estimate which plans would pay a greater share of a patient’s out-of-pocket costs.

See also: 10 plans summarize diabetes benefits

SBC update proposal

3. The reps think including a very high cost scenario is a good way to help consumers understand the value of health coverage.

Including a scenario involving an expensive, catastrophic event such as cancer treatment would be especially helpful, the reps say.

“A very high cost example was included in consumer testing and was the most motivational in terms of making insurance seem valuable and encouraging its purchase,” the reps say. 

See also: Witness: SBCs justify value of insurance